Friday, June 28, 2013

Ask a different question.

Today, a Mental Health Tribunal
has announced its decision that Ian Brady should remain a patient of Ashworth
Hospital.

So what does all this mean
about Mental Health Tribunals in cases such as these? First, in my opinion, the
central (and hugely important) issues for a Tribunal should be to answer two
key questions: what sort of care does a person require and, assuming they
disagree, are they psychologically capable of making that decision?

Issues of mental health and
psychological capacity are matters for deciding on the practicalities of where
(prison or secure hospital) the person should reside. Criminologists,
psychologists, sociologists and doctors must try to understand why people do
what they do, but the concept of “illness” is unhelpful. Questions of guilt
and the reasons for the commission of crimes are matters for criminal courts,
not Mental Health Tribunals.

In my opinion, this case is a
good example of how we need to re-think fundamental issues about mental health
and human behaviour. I do think – and it’s important to stress this – that
everybody has a right to be cared for in the manner most appropriate to their
needs.

The staff in psychiatric
hospitals have distinctive and hugely valuable skills needed to help people who
are suicidal, who self-harm, hear voices or are terrified by paranoid
delusions. We are all, including those convicted of criminal activity, entitled
to appropriate, high-quality care.

Of course, we might all agree
that a hospital is the right place, but the individual concerned may well
disagree. This is, in essence, the substance of many Tribunal decisions. I do
not believe that this issue is best addressed by asking if a person is “ill”.

Instead we need to consider
two key questions; a) is it clear that hospital care is the right course of
action?, b) in cases where the individual disagrees, are they in a position to
make a decision for themselves? If a person is able to make a rational decision
to refuse hospital care, in my opinion, that decision should stand. But that
decision shouldn’t be based on the question of “illness”. It should be based on
the person’s capacity to make a decision for themselves.

So, in my opinion, tribunals
should be focused squarely on the needs of the individual and their capacity to
make decisions, for themselves, about the care being offered.

Public discussion of Ian
Brady’s case, because of his notoriety and the unique experience of a public
Mental Health Tribunal, has also focused on issues of madness and
responsibility for crimes. And here, again, the issue of illness, in my
opinion, needs to be re-thought. We do need to understand and explain why
people behave in such ways, but I don’t think the language of “illness” helps
here either.

Although I think it’s
extremely unlikely, we do need to think about whether some biological
abnormality might be a factor in crimes of this nature. But if that were to be
the case, it’s close to impossible to see how such a finding would relate to
the diagnostic morass that all observers find themselves in (and always have).

For any diagnosis, the vast
majority with such a diagnosis would never commit crimes such as Brady’s, and
the vast majority of homicides are associated with no mental health diagnosis,
let alone a specific one. There are absolutely reasons why those convicted of
serious crime do what they do – and those reasons are psychological, social
and, perhaps even biological.

But it cannot be said that
“they did what they did because they are sick” is any kind of satisfactory
answer.